1
716 It was considered safe to leave only those cases in which the patient was already recovering when first seen. Mr. F. C. WALLIS said he would refer but to two points which had not been touched upon during the discussion. The first was the condition of the omentum in cases of acute appendicitis. He mentioned the case of a boy operated on for appendicitis in whom the omentum was infiltrated but not adherent. Three weeks after the operation symptoms of partial obstruction were present. The abdomen was opened and it was found that the small intestine was adherent to the omentum in two places. Two methods of treatment were possible in such a case, one to anchor the omentum and the other to remove it, and he was in favour of the second mode of treatment. The second point to which he referred was a protest against allowing patients to get up on the tenth or fourteenth day after the appendix had been removed. He considered that con- siderable risks were run by allowing patients to get up at so early a period after operation. Dr. G. NEWTON PITT said that he had come to the con- clusion that appendicitis had become more common. A marked increase occurred during 1889-90 and was coinci- dent with the prevalence of influenza. He was of opinion that there was both an increase in the incidence and in the mortality of the disease. The PRESIDENT regretted that Sir Frederick Treves was prevented from attending to conclude the discussion. He thought all would agree that that debate had been of extreme value. The subject of it had ripened through many years of experience, discussion, and criticism since it was first propounded at that society by Sir Frederick Treves in 1887, and it was particularly appropriate therefore that he should have introduced and reviewed it on this occasion. It must have been gratifying to him and to many other surgeons, most of whom had spoken in that debate, to watch the development of this domain of surgery to its present state of completeness. The great value of a discussion such as they had had, lasting through three prolonged and well- attended meetings, was that it had, for that time at least, concentrated the attention of both surgeons and physicians upon one particular problem in this case as to the best way of rendering the results of operations for appendicitis most satisfactory and of avoiding untoward complications. Many minds would have been settled as to the best modes of pro- cedure, many points decided in the course of the debate, and by the large statistical experience with which it had been enriched. 1. One point, for instance, insisted upon by Sir Frederick Treves and strongly advocated by Mr. Pearce Gould, Sir William Bennett, Mr. Cripps, and Mr. Bruce Clarke, was that in cases of perityphlitic abscess it was best, as a rule, not to try to remove the appendix when imbedded, as it generally was, in entangled adhesions. 2. Another point which seemed to come out very strongly in the debate, and which was referred to by Sir Frederick Treves and alluded to by Dr. H. P. Hawkins and Mr. W. H. Battle, was the fact that failures and subsequent complication of the operation were sometimes attributable to its not having been adequately performed-i.e., to the appendix not having been excised from its very origin at the cascum but only a portion cut off—and that this incomplete- ness of the operation was not infrequently due to the caecal end of the appendix being partially invaginated. 3. Then, again, there was the very difficult question which had been touched upon by more than one speaker-viz., when to operate-and this was a question which was also of great interest and importance to the physician who otherwise was perhaps more concerned with the con- ditions which led up to appendicitis which did not come within the scope of the debate. When the diagnosis of perityphlitic abscess had been arrived at of course the operation practically immediately followed. Mr. Cripps would not wait for abscess but would advise operation in the earlier stage of appendicitis. But great emphasis had rightly been laid by many speakers, especially by Mr. Pearce Gould. Mr. G. R. Turner, and Mr. H. F. Waterhouse, upon the importance of anticipating abscess by dealing with the appendix in what was called the quiescent period of appendicitis. This view must, of course, be guarded by great care in diagnosis, for whilst, on the one hand, if diseased appendices were allowed to remain there was the risk at any moment of abscess with general peritonitis, with the result of raising the mortality of operative interference to about 25 per cent. instead of 2 per cent. or less for the simple operation ; on the other hand, healthy appen- dices were sometimes removed, leaving behind the malady from which the patient had been promised relief. The danger must be recognised that the operation might be too lightly undertaken and might become too much of a routine practice and not sufficiently safeguarded by careful and accurate diagnosis. 4. Future complications in quiescent cases might be sometimes avoided by a careful preparation of the patient for a few days before the operation. 5. The. society was especially indebted to Mr. Lockwood for his most valuable contribution to the debate by illustrating so clearly on the screen those points in the pathology of diseased appendices which were so intimately concerned with the future of the cases operated on. 6. Another point of great importance to the future comfort of the patient was touched upon by several speakers-viz., especially in cases requiring large incisions, the avoidance as much as possible- in the first incisions of cutting across muscular fibre, the importance of separating rather than dividing the muscle with the view of obviating ventral hernia and the necessity afterwards of using a large and cumbersome truss. He could not let that opportunity pass without offering the sincere thanks of the society to those gentlemen who had taken part in the debate, and especially to those-Mr. Hugh Lett, Mr. W. H. Battle, Mr. G. E. Gask, Mr. A. Baldwin, Mr. W. G. Spencer, Mr. Barling, Mr. C. B. Lockwood, Dr. Lawrence- Jones, Dr. H. P. Hawkins, Mr. H. S. Clogg, and Mr. H. A. T. Fairbank-who had at great labour prepared the statistics of some thousands of cases which had been laid before the society. MEDICAL SOCIETY OF LONDON. Carcinoma. A MEETING of this society was held on March 13th, Mr. JOHN LANGTON, the President, being in the chair. Dr. E. F. BASHFORD read a paper on Carcinoma based on researches made under the auspices of the Imperial Cancer Research Fund. He said that he proposed to confine his, remarks to the "growth of cancer" and emphasised the fundamental importance of the study of its process of growth as distinct from its genesis. It was, in his view, the only effective method by which progress could be made in the solution of the problems as to the nature and the origin of cancer. He then gave some account of the work which had been accomplished by means of comparative and experi- mental methods, exhibiting a large number of lantern slides in illustration of various points of importance. He defined cancer as a malignant new growth. Many of the recent hypotheses enunciated to explain cancer had started with a theory of origin but failed to explain how the actual cell multiplication had been maintained in the gradual increase: of the tumours. PATHOLOGICAL SOCIETY OF LONDON. Recent Work on Proteid Chemistry and Proteid Diet. A MEETING of this society was held on March 7th, Dr, W. D. HALLBURTTON being in the chair. Dr. HALLIBURTON read a paper on Recent Work on Proteid Chemistry and Proteid Diet. The paper, he said, was the outcome of a request from certain members of the’ society that he should lay before them the results of recent progress in connexion with the chemistry and the dietetic value of the proteids. In the time at his disposal he was. only able to deal with this large and important question in its main features. The doctrine of Eubne that the albu- minous molecule consisted of hemi- and anti-complexes’ united together had been abandoned. With the dis- appearance of that conception interest centred around’ the final decomposition products such as were obtainable as the result of prolonged proteolysis. Before a synthesis was possible a correct knowledge of these cleavage products- was a preliminary necessity. These might be classified into the mono-amino acids like leucine and glycine, the diamino acids or hexone bases, the aromatic amino acids like tyrosine and tryptophane, members of the pyrrimidin and pyrrolidine groups, the sulphur-containing substance cystin, and ammonia. Particular attention was directed to the groups of amino acids called polypeptides which occurred as an intermediate stage in proteolysis between the peptones and the final products ; and the fact that Emil Fischer had synthesised some of these was an indication that such work might culminate in the actual synthesis of the proteid mole- cule. In connexion with proteid absorption the trend of recent..

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716

It was considered safe to leave only those cases in which thepatient was already recovering when first seen.

Mr. F. C. WALLIS said he would refer but to two pointswhich had not been touched upon during the discussion.The first was the condition of the omentum in cases of acuteappendicitis. He mentioned the case of a boy operated onfor appendicitis in whom the omentum was infiltrated butnot adherent. Three weeks after the operation symptomsof partial obstruction were present. The abdomen wasopened and it was found that the small intestine was

adherent to the omentum in two places. Two methodsof treatment were possible in such a case, one to anchorthe omentum and the other to remove it, and he was infavour of the second mode of treatment. The second pointto which he referred was a protest against allowingpatients to get up on the tenth or fourteenth day after theappendix had been removed. He considered that con-

siderable risks were run by allowing patients to get up atso early a period after operation.

Dr. G. NEWTON PITT said that he had come to the con-clusion that appendicitis had become more common. Amarked increase occurred during 1889-90 and was coinci-dent with the prevalence of influenza. He was of opinionthat there was both an increase in the incidence and in themortality of the disease.The PRESIDENT regretted that Sir Frederick Treves was

prevented from attending to conclude the discussion. He

thought all would agree that that debate had been of extremevalue. The subject of it had ripened through many yearsof experience, discussion, and criticism since it was first

propounded at that society by Sir Frederick Treves in 1887,and it was particularly appropriate therefore that he shouldhave introduced and reviewed it on this occasion. It musthave been gratifying to him and to many other surgeons,most of whom had spoken in that debate, to watch thedevelopment of this domain of surgery to its present stateof completeness. The great value of a discussion suchas they had had, lasting through three prolonged and well-attended meetings, was that it had, for that time at least,concentrated the attention of both surgeons and physiciansupon one particular problem in this case as to the best wayof rendering the results of operations for appendicitis most

satisfactory and of avoiding untoward complications. Manyminds would have been settled as to the best modes of pro-cedure, many points decided in the course of the debate, andby the large statistical experience with which it had beenenriched. 1. One point, for instance, insisted upon by SirFrederick Treves and strongly advocated by Mr. Pearce

Gould, Sir William Bennett, Mr. Cripps, and Mr. Bruce

Clarke, was that in cases of perityphlitic abscess it was best,as a rule, not to try to remove the appendix when imbedded,as it generally was, in entangled adhesions. 2. Another

point which seemed to come out very strongly in the debate,and which was referred to by Sir Frederick Treves andalluded to by Dr. H. P. Hawkins and Mr. W. H. Battle,was the fact that failures and subsequent complicationof the operation were sometimes attributable to its not

having been adequately performed-i.e., to the appendixnot having been excised from its very origin at the cascumbut only a portion cut off—and that this incomplete-ness of the operation was not infrequently due to thecaecal end of the appendix being partially invaginated.3. Then, again, there was the very difficult question whichhad been touched upon by more than one speaker-viz.,when to operate-and this was a question which was alsoof great interest and importance to the physician whootherwise was perhaps more concerned with the con-

ditions which led up to appendicitis which did not comewithin the scope of the debate. When the diagnosis ofperityphlitic abscess had been arrived at of course the

operation practically immediately followed. Mr. Crippswould not wait for abscess but would advise operation inthe earlier stage of appendicitis. But great emphasis hadrightly been laid by many speakers, especially by Mr.Pearce Gould. Mr. G. R. Turner, and Mr. H. F. Waterhouse,upon the importance of anticipating abscess by dealing withthe appendix in what was called the quiescent period of

appendicitis. This view must, of course, be guarded bygreat care in diagnosis, for whilst, on the one hand, ifdiseased appendices were allowed to remain there was therisk at any moment of abscess with general peritonitis, withthe result of raising the mortality of operative interferenceto about 25 per cent. instead of 2 per cent. or less forthe simple operation ; on the other hand, healthy appen-dices were sometimes removed, leaving behind the malady

from which the patient had been promised relief. The

danger must be recognised that the operation might be toolightly undertaken and might become too much of a routinepractice and not sufficiently safeguarded by careful andaccurate diagnosis. 4. Future complications in quiescentcases might be sometimes avoided by a careful preparationof the patient for a few days before the operation. 5. The.society was especially indebted to Mr. Lockwood forhis most valuable contribution to the debate by illustratingso clearly on the screen those points in the pathology ofdiseased appendices which were so intimately concerned withthe future of the cases operated on. 6. Another point ofgreat importance to the future comfort of the patient wastouched upon by several speakers-viz., especially in casesrequiring large incisions, the avoidance as much as possible-in the first incisions of cutting across muscular fibre, theimportance of separating rather than dividing the musclewith the view of obviating ventral hernia and the necessityafterwards of using a large and cumbersome truss. He couldnot let that opportunity pass without offering the sincerethanks of the society to those gentlemen who had taken partin the debate, and especially to those-Mr. Hugh Lett, Mr.W. H. Battle, Mr. G. E. Gask, Mr. A. Baldwin, Mr. W. G.Spencer, Mr. Barling, Mr. C. B. Lockwood, Dr. Lawrence-Jones, Dr. H. P. Hawkins, Mr. H. S. Clogg, and Mr. H. A. T.Fairbank-who had at great labour prepared the statistics ofsome thousands of cases which had been laid before the

society.

MEDICAL SOCIETY OF LONDON.

Carcinoma.A MEETING of this society was held on March 13th, Mr.

JOHN LANGTON, the President, being in the chair.Dr. E. F. BASHFORD read a paper on Carcinoma based on

researches made under the auspices of the Imperial CancerResearch Fund. He said that he proposed to confine his,remarks to the "growth of cancer" and emphasised thefundamental importance of the study of its process of growthas distinct from its genesis. It was, in his view, the onlyeffective method by which progress could be made in thesolution of the problems as to the nature and the origin ofcancer. He then gave some account of the work which hadbeen accomplished by means of comparative and experi-mental methods, exhibiting a large number of lantern slidesin illustration of various points of importance. He definedcancer as a malignant new growth. Many of the recent

hypotheses enunciated to explain cancer had started with atheory of origin but failed to explain how the actual cellmultiplication had been maintained in the gradual increase:of the tumours.

PATHOLOGICAL SOCIETY OF LONDON.

Recent Work on Proteid Chemistry and Proteid Diet.A MEETING of this society was held on March 7th, Dr,

W. D. HALLBURTTON being in the chair.Dr. HALLIBURTON read a paper on Recent Work on

Proteid Chemistry and Proteid Diet. The paper, he said,was the outcome of a request from certain members of the’society that he should lay before them the results of recentprogress in connexion with the chemistry and the dieteticvalue of the proteids. In the time at his disposal he was.only able to deal with this large and important question inits main features. The doctrine of Eubne that the albu-minous molecule consisted of hemi- and anti-complexes’united together had been abandoned. With the dis-appearance of that conception interest centred around’the final decomposition products such as were obtainable asthe result of prolonged proteolysis. Before a synthesiswas possible a correct knowledge of these cleavage products-was a preliminary necessity. These might be classifiedinto the mono-amino acids like leucine and glycine, thediamino acids or hexone bases, the aromatic amino acids liketyrosine and tryptophane, members of the pyrrimidin andpyrrolidine groups, the sulphur-containing substance cystin,and ammonia. Particular attention was directed to thegroups of amino acids called polypeptides which occurred asan intermediate stage in proteolysis between the peptonesand the final products ; and the fact that Emil Fischer hadsynthesised some of these was an indication that such workmight culminate in the actual synthesis of the proteid mole-cule. In connexion with proteid absorption the trend of recent..